Tag: NHS

Factors associated with accessing long-term social care in older people

The rise in demand for healthcare by an ageing population together with budgetary constraints has put great pressure on the availability of adult social care (ASC). In response, healthcare organisations and researchers have developed practices of care and support, focusing on prolonging functional independence  This is done through exploring possible risk factors associated with unplanned outcomes, typically readmissions to hospital or through the use of predictive models to forecast outcomes.

Predictive models are widely used by health care providers in the UK and US due to their potential to inform early interventions. However, equivalent models for predicting new onset of long-term ASC, defined as need for help with tasks of daily living in the community or in care homes, are rare, particularly those using administrative data.

In this study published in Age and Ageing, we describe risk factors for long-term ASC in two inner London boroughs and develop a risk prediction model for long-term ASC. Pseudonymised person-level data from an integrated care dataset were analysed. We used multivariable logistic regression to model associations of demographic factors, and baseline aspects of health status and health service use, with accessing long-term ASC over 12 months.

The cohort comprised 13,394 residents, aged ≥75 years with no prior history of ASC at baseline. Of these, 1.7% became ASC clients over 12 months. Residents were more likely to access ASC if they were older or living in areas with high socioeconomic deprivation. Those with pre-existing mental health or neurological conditions, or more intense prior health service use during the baseline period, were also more likely to access ASC. A prognostic model derived from risk factors had limited predictive power.

Our findings reinforce evidence on known risk factors for residents aged 75 or over, yet even with linked routinely collected health and social care data, it was not possible to make accurate predictions of long-term ASC use for individuals. We propose that a paradigm shift towards more relational, personalised approaches, is needed.

DOI: https://doi.org/10.1093/ageing/afac038

Should GPs in England be employed by the NHS?

The intense micromanagement of general practices by NHS England since the start of the Covid-19 pandemic in early 2020 has shattered the illusion that NHS general practitioners are truly “independent”. For example, during the pandemic, NHS general practices have often received weekly updates from NHS England on how they should provide primary care services.[1] The opening hours and working arrangements of general practices are also highly regulated by NHS England. And general practitioners are not independent contractors in the same way that professionals working in other fields or indeed primary care physicians working overseas would recognise. General practitioners are not even able to offer private medical services to their patients in the same way as NHS Trusts or dentists are able to do. In effect, they have all the disadvantages of being self-employed contractors and none of the benefits of being NHS employees.

For more than a decade, primary care in England has suffered from under-investment, and a lack of key staff such as general practitioners and practice nurses. The NHS hospital sector in contrast – although it also has its problems – has seen its funding and medical staffing increase at a much quicker rate than in NHS primary care.[2] And yet despite this, more NHS work continues to be shifted to primary care without being followed by a commensurate increase in funding and staffing. Attempts by NHS England to prevent this – such as the introduction of the NHS Hospital Contract – have failed.[3] It’s very clear that NHS England is not going to invest adequately in the current independent contractor model of general practice, making being a GP Partner increasingly unattractive for younger general practitioners.[4] It’s time therefore to look seriously at the alternative – GPs becoming salaried employees of the NHS.

Of course, being employed by the NHS is not a panacea. Many NHS staff employed by NHS Trusts suffer from stress and over-work, just like those working in primary care. But they are not personally responsible for the ownership of their employing organisations, and their income does not depend on how well their organisation performs financially. Their working hours are also better regulated than those of self-employed GPs.

If GPs had employment contracts similar to those of NHS consultants, they could then have job plans with time allocated for activities such as quality improvement, NHS management, teaching, training, and research. Currently, these activities are often done on top of their regular working hours. Working in organisations that employed large numbers of GPs would also create opportunities for a better career structure. For example, it may be possible to create posts for GPs who specialise in areas such as the care of the elderly or in child health; and for GPs who take on clinical leadership, quality improvement and NHS management roles in addition to a clinical role.[5]

Finally, GPs becoming NHS employees would make NHS England directly responsible for the delivery of primary care services, in the same way they already are for specialist services. It would be the responsibility of NHS England – not GPs – to ensure that patients had timely access to a comprehensive range of high-quality primary care services and the infrastructure needed to deliver this care.

An increasing proportion of NHS GPs are already salaried. The future for GPs therefore looks to be heading in this direction. The question for GPs is do they want to be employed by the NHS with similar terms of employment to consultants; or do they want to be employed by private companies and “mega-partnerships” with the inevitable variability in terms of employment that they will offer?

A version of this article was first published in the British Medical Journal.

DOI: https://doi.org/10.1136/bmj.o406


1. Majeed A, Maile EJ, Bindman AB. The primary care response to COVID-19 in England’s National Health Service. Journal of the Royal Society of Medicine. 2020;113(6):208-210.

2. Anderson M, O’Neill C, Clark JM, Street A, Woods M, Johnston-Webber C, et al. Securing a sustainable and fit-for-purpose UK health and care workforce. The Lancet. 2021 May 22;397(10288):1992-2011.

3. Price A, Majeed A. Improving how secondary care and general practice in England work together: requirements in the NHS Standard Contract. Journal of the Royal Society of Medicine. 2018;111(2):42-46.

4. Rimmer A. GPs move towards industrial action after rejecting “rescue plan” for general practice BMJ 2021; 375:n2594

5. Majeed A, Buckman L. Should all GPs become NHS employees? BMJ 2016; 355:i5064

General Practice in England: The Current Crisis, Opportunities and Challenges

General practice or family medicine has historically been lauded as the “jewel in the crown” of the English National Health Service (NHS). General practice, at the heart of primary care, has continued to contribute to the high ranking of the NHS in international comparisons and evidence from several decades of research has shown that general practice in the UK has improved the nation’s health. Furthermore, it has provided equitable, cost-effective, and accessible care for all with the flexibility to adapt rapidly to a changing society and political climates, such as during the COVID-19 pandemic when there was rapid implementation of remote consultation models. However, this much-admired public sector service has recently come under unprecedented political and media spotlight instigated by the pressures of the current pandemic on the NHS. This coupled with collapsing morale among general practitioners (GPs), a shrinking GP workforce, inexorable demands, increasing workload, and decreasing real-terms per capita funding have caused many to sound alarm on a general practice in “crisis”. In this article published in the Journal of Ambulatory Care Management, we describe the evolving nature of general practice and the current crisis, as well as potential solutions and opportunities going forward.

The full article can be read in the Journal of Ambulatory Care Management.

DOI: 10.1097/JAC.0000000000000410

A national vaccination service for the NHS in England

The Health Secretary, Sajid Javid, announced on 26 January that a ‘national vaccination service’ is required to provide mass covid-19 vaccination to the population of England.[1] Speaking at a House of Commons Health and Social Care Committee meeting, Mr Javid suggested the proposed service could cover other vaccines as well as vaccines for covid-19. The rationale is that NHS General Practice is under great strain, and by removing some services that can be provided elsewhere, it will free up time for primary care teams to concentrate on their core work.

Traditionally, mass vaccine programmes in England have relied largely on general practices, increasingly supported by community pharmacies in recent years. This was demonstrated to great effect during the first wave of covid-19 vaccinations where the majority of vaccines were delivered by primary care teams. GP teams have secure electronic patient record systems, and are experienced in cold storage chains, and have medical support on site, including resuscitation equipment. Patients often know and trust their family doctors, and generally respond better to recalls for vaccination when these come from their own general practices. A move towards mass vaccine centres and away from primary care delivery may explain some of the recent slow-down in England’s covid-19 vaccine programme.[2]

The public need to be fully informed about what a national vaccination service will mean for them individually as well as the NHS. The majority of all NHS contacts occur in general practice, with around one million contacts per day.[3] This means that vaccines can be offered opportunistically when patients are attending for other reasons as well as in dedicated vaccine clinics. It also allows primary care teams to have discussions about vaccination during these consultations in patients who have concerns or questions about vaccines, or who are vaccine hesitant.

When attending for vaccination, patients also have the opportunity to discuss other issues in their health with their primary care team and to benefit from opportunistic health promotion. All this helps to ensure that vaccination is viewed holistically and not just as a transactional activity. This is particularly important for children where non-attendance for vaccination can sometimes be a safeguarding issue which requires a sensitive approach from primary care teams, as well as effective inter-agency working.

When the Prime Minister, Boris Johnson, announced that he wanted all adults England to be offered a covid-19 vaccine before the end of 2021 he looked to GPs to help. As a result, GPs were asked to drop all non-essential work and focus on vaccination for the remainder of the year. This caused much debate in the national and medical press about what the priorities should be for the NHS and for primary care. Suspending “non-essential work” will have adverse effects on people’s experience of the NHS and risks worsening health outcomes, particularly for poorer groups.[4] It is clearly also a policy that cannot be sustained for long or repeated frequently (for example, for another covid-19 vaccine booster programme later this year).

The current plan to consider a separate national vaccination service for covid-19 and possibly other vaccinations seems to be an effort to ensure that GPs are not asked to stop routine medical care again. Although investment in the NHS is welcome, and removing some workload from general practice might have merits, there are some caveats that must be considered before a new national vaccination service is established.

Firstly, any new vaccination service must be more cost-effective than existing models of delivery of vaccines, such as through general practices and pharmacists. At a time when NHS budgets are under great pressure, NHS funding must be used cost-effectively and services delivered efficiently. A new national vaccination service would require substantial funding to establish and run. For example, it is difficult to see how a national vaccine service could run effectively without full access to patients’ electronic medical records. It would also require premises from which to operate, and staff to manage and deliver the programme. We need the government to show how this investment in a new service would compare in terms of cost-effectiveness with a similar investment in primary care teams.

Secondly, a national vaccination service must achieve a high uptake of vaccination. We currently have very good uptake of most childhood vaccines in England and in 2021-22, primary care teams also achieved a record uptake of flu vaccines, for an extended group of patients compared to previous years. Vaccinations must also be delivered quickly and at scale when in a pandemic, and there must be a safe and robust system to target high risk groups; such as those with frailty, long term conditions, the housebound, people living in care homes, and patients from marginalised groups.[5]

Thirdly, creating a separate vaccination service risks further fragmentation of primary care. As we have already seen with the covid-19 NHS 119 service, many patients will still contact their GPs about vaccination queries, even if this is no longer part of the NHS GP contract. This risks creating extra work for primary care teams that is not part of their core contract and for which they will not be paid; and will also be very frustrating for patients who will have to deal with more than one healthcare provider to have any issues they have about their vaccinations and how these vaccinations are recorded are dealt with. Finally, a newly established national vaccine service may recruit staff from primary care teams, both clinical and non-clinical, thereby further worsening the current shortages of staff in NHS primary care.[6]

The government must therefore carefully examine the merits of a separate national vaccination service; and any problems it may cause for existing services; including how it might affect vaccine uptake. Investing in and strengthening existing NHS primary care infrastructure in general practices and pharmacies may be a more cost effective option. Because of the importance of vaccination in allowing England to move to “living with covid-19”, vaccinations programmes must be implemented well and achieve a high take-up, particularly in the groups most at risk of serious illness, complications and death from infectious diseases such as covid-19. We cannot risk undermining the current vaccination systems that already work efficiently and cost-effectively in England’s NHS. Any proposals for a new national vaccination service must therefore be assessed with the same rigour we would with any new medical treatment with serious consideration of the risks as well as the benefits.

 A version of this article was first published in the British Medical Journal.

DOI: https://doi.org/10.1136/bmj.o338


  1. Health secretary proposes ‘national vaccination service’ to relieve GPs.https://www.pulsetoday.co.uk/news/breaking-news/health-secretary-proposes-national-vaccination-service-to-offload-gps/
  2. Where are we with covid-19 vaccination in the United Kingdom?https://blogs.bmj.com/bmj/2021/07/09/where-are-we-with-covid-19-vaccination-in-the-united-kingdom/
  3. Appointments in General Practice.https://digital.nhs.uk/data-and-information/publications/statistical/appointments-in-general-practice–weekly-mi/current
  4. Majeed A, Maile EJ, Bindman AB. The primary care response to COVID-19 in England’s National Health Service. Journal of the Royal Society of Medicine. 2020;113(6):208-210.
  5. Covid-19 vaccines: patients left confused over rollout of third primary doses.https://blogs.bmj.com/bmj/2021/10/15/covid-19-vaccines-patients-left-confused-over-rollout-of-third-primary-doses/
  6. Oliver D. Act on workforce gaps, or the NHS will never recover BMJ 2022; 376:n3139

The NHS needs urgent support as we enter the most challenging period of the pandemic yet

On Friday 17 December, a record number of Covid-19 cases (93,045) was reported in the UK.  Unfortunately, the recently identified Omicron variant has proven to be considerably more infectious than previous variants. Vaccines are also less effective against Omicron, with two doses of the vaccine providing only limited protection from symptomatic Covid-19 infection. A booster (third) dose increases protection but not to the level seen against other variants.

Although the clinical severity of Omicron-linked cases is still to be fully determined, the sheer volume of cases will lead to greater pressures on all sectors of England’s NHS. This comes at a time when the NHS in England is already struggling to cope with existing demands, whilst also trying to manage the enormous backlog that has built up since the start of the pandemic in early 2020.

With the NHS now tasked with substantially increasing the number of Covid-19 vaccines available, we are entering a very challenging period, juggling; the increased rollout of Covid-19 vaccinations, a surge in Covid-19 cases, usual winter pressures, such as seasonal respiratory infections and other urgent medical problems, and maintaining rapid access to care for people with suspected cancer.

Other important areas of work also need to continue. This includes childhood vaccinations, mental health services, and community care for vulnerable patients. Inevitably, much of the elective work that the NHS does will have to be deferred, leading to yet further increases in NHS waiting lists for specialist care. There will be less capacity to defer elective NHS care in general practices, leading to further frustrations from patients, if access to primary care services is curtailed.

Unfortunately, due to these challenges a deterioration in health outcomes will occur. It is not always easy to separate out urgent from non-urgent medical problems. If people are asked to defer seeking care, some patients will inevitably suffer delays to their diagnosis.

It is essential that access to primary care services is maintained during this challenging time. Unfortunately, many community healthcare providers are already suffering from long-standing workforce shortages that cannot be easily addressed. Ideally, expanding Covid-19 vaccination capacity would be in addition to, rather than in place of, these services. But this requires rapid planning at national and local level, and a willingness to give local clinicians the autonomy to develop their own solutions without the bureaucratic hurdles that are often the hallmark of the NHS.

The continued waves of infection the NHS has faced since the start of the pandemic have taken a considerable toll on the physical and mental health of NHS staff. The largest wave of infection yet, from Omicron, will add further to this toll. As well as the direct risks from Covid-19, an infection that has disproportionately affected healthcare workers, the mental health of NHS staff has also been adversely affected; with high levels of problems such as stress, burnout and post-traumatic stress disorder. This in turn has led to high levels of absence due to illness, which further compounds the pre-existing shortages of staff. Recognising the impact of working during the pandemic on healthcare professionals is essential, as are initiatives to improve the well-being of staff.

The NHS is entering one of its most challenging phases – probably more challenging than the previous two large Covid-19 waves in March 2020 and January 2021. The public need to understand that the NHS urgently need support. In the worst-case scenario, this could mean the NHS being placed on an emergency footing for several months if there are very high numbers of Omicron cases and the reduced effectiveness of vaccines lead to a prolonged increase the number of severely ill patients in need of NHS care.

A version of this article was first published in The House Magazine.

Lancet Commission on the Future of the UK’s NHS

I would like to thank the Lancet for giving me the opportunity to contribute to their Commission on the Future of the NHS. I fully support the recommendation for a strong and sustained increase in NHS funding to address the current weaknesses in the NHS. For me, the most striking data in the Lancet Commission on the Future of the NHS was this figure, taken from Securing a sustainable and fit-for-purpose UK health and care workforce, showing the changes in the number of NHS GPs and consultants per 1,000 people between 2008-18. Note the decline in GP numbers compared to the increase in consultant numbers. Although we hear a lot from NHS managers and politicians about the need to shift the focus of the NHS to the community, staffing statistics do not support this. The reality is that NHS primary care funding and workload need to reflect staff levels, not meaningless rhetoric.

Figure: Numbers of GPs and hospital consultants across the UK per 1000 people, 2008–18

Covid-19 in London

The Covid-19 situation in London is now very serious, with the number of Covid-19 cases doubling in the past to week to around 50,000. Infection rates are highest in the North-East of London, with increases seen all across the city.

The number of hospital patients with Covid-19 has increased to around 3,000 compared with around 1,600 one month ago. The number of patients requiring ventilators has increased by 100 over the last week to around 360. There are also pressures on other parts of the NHS, such as GP, mental health, and community services.

The new strain of SARS-CoV-2 is now becoming the most commonly identified strain in London and the South-East of England. It appears to be more infectious than other strains, and this will drive up the number of cases, people requiring hospital treatment and deaths.

The latest statistics show how rapidly the situation can change. From a period around one month ago, when case numbers were falling and NHS pressures were sustainable, we are now on a trajectory of rapidly increasing cases, hospital admissions and deaths in London.

Urgent action is needed to control the Covid-19 pandemic on London, protect its population and reduce pressure on the NHS. This requires everyone to strictly follow the local Tier 4 rules. In particular, mixing indoors with people from other households should be avoided.

Most transmission of infection occurs indoors and it is stopping mixing of people from different households in indoor settings that is the key to breaking chains of infection. Other measures, such as wearing face masks in public spaces and good hygiene, are also essential.

We do now have one vaccine for Covid-19 licensed for use in the UK. We urgently need other vaccines to be approved for use; along with a massive increase in supply of vaccines and mobilisation of the NHS to deliver vaccines to the population on a speed and scale not previously seen in the UK.

Table: London boroughs by highest number of COVID-19 positives per 100k population.7–day rolling rate by specimen date – ending Dec 17. The table is from @UKCovid19Stats.

What are the priorities for the NHS during the period when tight Covid-19 restrictions are in place?

People in many areas of the United Kingdom will be living under tight Covid-19 restrictions for the next few months. In London and the South-East of England, for example, this means being placed under Tier 4 restrictions.

For the NHS, there will be two main priorities during this period. The first will be to rapidly implement the Covid-19 vaccination programme. This is our best hope of bringing the pandemic under control and allowing life to start to return to normal. But success requires working on a speed and scale not seen before for any public health programme in the United Kingdom. Adequate supplies of vaccine must be secured and the infrastructure put in place to administer vaccines rapidly to tens of millions of people.

The second priority will be to ensure that people with non-Covid illnesses receive the care they need. This will be very challenging in the middle of a pandemic. We have already seen a large backlog of NHS work build up in 2020. The NHS must ensure that people receive the healthcare they need at this difficult time; whether this is in general practice, mental health, or hospital settings to prevent a rise in ill-health and deaths from non-Covid related causes.

Health outcomes in the UK: how do we compare with Europe?

In an article published in the British Medical Journal, I discuss the health outcomes achieved by the NHS in the UK and how these compare with other European countries. Health outcomes in the UK have improved substantially since the NHS was established in 1948. The NHS also performs well in many international comparisons on measures such as efficiency, equity, and access.

Despite these achievements, however, problems with health outcomes remain. Moreover, other European countries have also improved their health outcomes in recent decades, often at a faster rate than the UK. Consequently, the UK now lags behind many other European countries in key health outcomes in areas such as child health and cancer survival.

I conclude that new health policies in the UK should help the NHS to focus on improving health outcomes and that politically expedient schemes that are not evidence-based – such as extended opening hours in primary care – should be abandoned. Continued progress is also needed on wider determinants of health such as poverty, housing, education, employment, and the environment.

Public Health and Primary Care in England: What does the future look like?

I spoke at a joint training day for primary care and public health registrars in London on the topic of Public Health and Primary Care in England: What does the future look like?

The key points from my presentation were:

  • Some new NHS investment – but investment is very low by historical standards
  • Will the new models of healthcare delivery deliver the £22 billion efficiency savings the Treasury expects?
  • What impact will contractual changes have? Junior doctors, consultants, GPs, public health consultants
  • Can primary care attract and retain enough doctors?
  • What impact will cuts in public health budgets have on health improvement programmes and on careers in the specialty?

My presentation can be viewed on Slideshare.